42-038 (2) B -2022-1668
721 WESTHAMPTON RD COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
42-038-001 CITY OF NORTHAMPTON
Permit: Alts Renovations
Repair
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
BUILDING PERMIT
Permit# BP-2022-1668 PERMISSION IS HEREBY GRAN ED TO:
Project# ADD BATH 2022 Contractor: License:,
Est. Cost: 23400 RHI CONSTRUCTION 055236
Const.Class: Exp.Date: 01/18/2024
Use Group: Owner: KAGAN AARON W&ELISA A MANNING
Lot Size (sq.ft.)
Zoning: WSP Applicant: RHI CONSTRUCTION
Applicant Address Phone: Insurance:
128 RYAN RD 413-885-9038 7PJUB1K06038421
FLORENCE, MA 01062
ISSUED ON: 01/03/2023
TO PERFORM THE FOLLOWING WORK:
ADD 1/2 BATH TO 1ST FLOOR
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Underground: Service: Meter: Footings:
Rough: Rough: House # Foundation:
Final: Final: Final: Rough Frame:
Gas: Fire Department Driveway Final: Fireplace/Chimney:
Rough: Oil: Insulation:
Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIO ATION OF
ANY OF ITS RULES AND REGULATIONS.
Signature:
1A - sA
Fees Paid: S152.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Office of the Building Commissioner
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The Commonwealth of Massachusetts I DEC 2
Board of Building Regulations and Standar 9 _02il
?MLrtvl O IT Y
Massachusetts State Building Code, 780 CI
° nun S
' �'' r� - T ised ar 2011
Building Permit Application To Construct,Repair,Renovate(�r'l emo l'$pr�, .s
One-or Two-Family Dwelling -
This Sectio For Official Use Only
Buildingpermit Number: >.2-- ,G( CG, V Date Applied:
Kter,3 Z i��G� /- 2023
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
—t Z' w -1-► UL.-
1.1 a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions: 1
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) - 1
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private 0 Zone: _ Outside Flood Zone? Municipal 0 On site disposal system 0
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
\: (V\c.nn%^' ?-k. rt. t- MO,- Ol_0(02
Name(Print) City,State,ZIP
1 L\ wt)*r\04-P\-n -- (9_11- 0/7.)—_�1 C
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s) 0 Alteration(s) 01 Addition 0
Demolition ❑ Accessory Bldg. 0 Number of Units Other 0 Specify:
Brief Description of Proposed Work':
(t-1. 'I-7 ( ,,-v-ti G r \ - -( (cur
pt1'� _ 5 K1t1 tw ko
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1.Building . $ \-A y Uv .$$ 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ 0 Standard City/Town Application Fee
S(JUU,Ur, 0 Total Project Costa(Item 6)x multiplier x
3.Plumbing $ '`U UU_W 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees $ Cil
Check No.3 0}Check Amount: �`�
6.Total Project Cost: $ z3\-(0).6-6" 0 Paid in Full 0 Outstanding Balance Due: 1
City of Northampton
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�li. 1 4 ' ' DEPARTMENT OF BUILDING INSPECTIONS ,.,
�. 212 Main Street • Municipal Building �1 a;
� Northampton, MA 01060 Isy �ti�� `
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PROCEDURE FOR OBTAINING A BUILDING PERMIT FOR WINDOWS,
DOORS, ROOFS, RENOVATIONS, ROOF MOUNTED SOLAR,ETC.
1. Building Permit Application signed by legal owner and filled out
by owner or authorized agent.
2. One set of plans and specification of proposed work(digital and hard copy).
3. Construction Debris Affidavit filled out and signed by applicant.
4. Worker's Compensation Insurance Affidavit filled out and signed by applicant.
5. Contractors must supply a copy CSL, HIC, and proof of Liability Insurance.
6. Energy Conservation Compliance Certificate (new/replacement windows).
7. Homeowner's License Exemption Form(if applicable).
8. Note any Special Permit requirements (if applicable).
9. Energy Code—all new construction(Gut/Rehab)requires an HERS Rater Affidavit.
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
i S—USS` (a \—tr-Z1/4-I
( \ _ License Number Expiration Date
Name of CSL Holder V
\Ole ^ List CSL Type(see below)
No.and Street— `L T Description
0\0& 1 (U� Unrestricted(Buildings up to 35,000 cu.ft.)
City/Town,State,ZIP l� � Restricted 1&2 Family Dwelling
M Masonry
. RC Roofing Covering
WS Window and Siding
\ SF Solid Fuel Burning Appliances
`A - c(;Yf -c % ytyc „vQ,-f' I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
ci' t t"SstR/ C. k 61 Sri
C c� ^� HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
No.and St*et Email address
-t ,.� ec U WV', L1\3— A1�f
City/Town,State,ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.§ 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes ❑ No ❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I
I,as Owner of the subject property,hereby authorize ' - fie. % --
to act on my behalf,in all matters relative to work authorized by this building permit application.
•
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Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNER`OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
`''-'0\O. ...4.•4 rnt\0,4.� \Z Z'l Z Z
Print Owner's or Authorized Agent s N e(Electronic Signature) Date
NOTES:
1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at
www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.eov./dps
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basement/attics,decks or porch)
Gross living area(sq.ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
Ihst:
1111111111111111MMIIIIIIIII• The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street,Suite 100
Boston,MA 02114-2017
p_ ,
oovw.ntass.gor/dia
11Atkers' t:ompensation Insurance Affidavit:BuitdersVContractors,'Electricians.'Plumbers.
10 HE FILED V,till IRE PERMITTING AlTIIORI 111.
Annlicant Information Please Print iteibili
Name(Business;Organizationilndividuatr
Address:
CityiState/Zi p: Phone #:
Are you an employ ell eke&the tpereprirate boa: Type of project(required):
irl I am a emplvyti with_ _employees(MI arulior part-timel.* 7. 0 New construction
2.11 I am a sole proprietor or partnership and have no employees working for me in 8. CErketrodeling
,riv caraway_[No workers comp.insuranee recithred]
9. D Demolition
3t]I am a homeowner doing all wort myself.[No workers'conip.insurance required.]
iOfl tii1ding addition
; I am a humeowner and will tie hiring mintradors to conduct all work on my property. I will
ensure that all contractont either have workers'compemation inaurani.v or are sole 1 i Electrical repairs or additions
j ipmetors with no employees.
lipfc
12.0 Plumbing repairs or additions
.I ama general contractor and I have hired the sub-euntractors listed on the all:Idled ale.el
I.3.0 Roo/repairs
tticse sub-contractors have employees and have workers'comp.in ce.suran
6.0 We're a corporation and its officers have exercised their right arm:rot:hint per ItifiL c. 14.00ther
152,i1(4).and we h..o,e no empluyerS.[No workers'coop.nnitaranee requevd.1 .
_
°My applicant that checks box 01 must also fill out the section below showing their workers'compensation policy information_
t tiorneowners w ho submit ihii affidavit indicating they arc doing all work and then lure outside contractors must submit a new affidavit indicating such.
:Contractors that cheek this bes must att.a.:Ived an additional sheet showing the name of the tub-contractors and state whether or not those entities,have
employees_ It tlic sub-contractors h.c.e employees.they mint provide,their workers'°amp.policy nLunber.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: ANI"\t) IC, Ur)\ekvv.Nple . C \—'s\')I-•CV"*. ) _
Policy#or Self.ins. Lie. : Expiration Date:
Job Site Address: -12 1 Vit..,)\--kke -..r.‘ 0-?..- City/State:Z irl ,calvte 41,- (1)t(il,
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under NIGL c. 152,*25A is a criminal violation punishable by a fine up to$1,500.00
and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage i.eritication.
1 do hereby certify under the pains and penalties ofperjury that doe information provided above is true and correct.
Signature: Date:
Phone 'zt:
Official use only. Do not write in this area,to he completed by city or town officiat
City or Town: Perinit'License
Issuing Authorit (circle one):
I. Board of Health 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing,Inspector
6.other
, Contact Person: • none a:
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City of Northampton
R
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DEPARTMENT OF BUILDING INSPECTIONS " ?x'
,,y 212 Main Street • Municipal Building �,
a`11*
Northampton, MA 01060 'r:'k *..)V'1'
CONSTRUCTION DEBRIS AFFIDAVIT
(FOR ALL DEMOLITION AND RENOVATION PROJECTS)
In accordance of the provisions of MGL c 40, S54, a condition of Building Permit
Number is that all debris resulting from this work shall be disposed of
in a properly licensed waste disposal facility, as defined by MGL c 111, S 150A.
The debris will be disposed of in:
Location of Facility: V4,_k. ,\
The debris will be transported by:
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Name of Hauler: 7 31-A
Signature of Applicant: Date: V1_ _ Z�
City of Northampton
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' Massachusetts �4? .%�.
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,;r DEPARTMENT OF BUILDING INSPECTIONS � ,,
ltL212 Main Street • Municipal Building p � `
' fir, Northampton, MA 01060 3byj�t`
HOMEOWNERS'EXEMPTION ELIGIBILITY AFFIDAVIT
I, (insert full legal name), born (insert
month, day, year), hereby depose and state the following:
1. I am seeking a building permit pursuant to the homeowners'exemption to the permit requirements of the
Massachusetts State Building Code, codified at 780 CMR 110.R5.1.3.1, in connection with a project or
work on a parcel of land to which I hold legal title.
2. I am not engaged in, and the project or work for which I am seeking the aforementioned homeowners'
exemption, does not involve the field erection of manufactured buildings constructed in accordance with
780 CMR 110.R3.
3. I qualify under the State Building Code's definition of"homeowner"as defined at 780 CMR 110.R5.1.2:
Person(s) who owns a parcel of land on which he/she resides or intends to reside, on which
there is, or is intended to be, a one-or two-family dwelling, attached or detached structures
accessory to such use and/or farm structures. A person who constructs more than one home in
a two-year period shall not be considered a home owner.
4. I do not hold a valid Massachusetts construction supervision license and, except to the extent that I
qualify for and will abide by the Massachusetts State Building Code's requirements for the supervision of
the project or work on my parcel, I am not engaged in construction supervision in connection with any
project or work involving construction, reconstruction, alteration, repair, removal or demolition
involving any activity regulated by any provision of the Massachusetts State Building Code.
5. If I engage any other person or persons for hire in connection with the aforementioned project or work on
my parcel, I acknowledge that I am required to and will act as the supervisor for said project or work.
Signed under the pains and penalties of perjury on this, day of , 20 .
(Signature)
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The Commonwealth of Massachusetts
! AL Department of Industrial Accidents
iir =; I=f 1 Congress Street.Suite 100
'"�,i.T -.. ,. Boston,MA 02114-2017
sown mass.govldia
11 orkers'Compensation Insurance Affidavit:BuiklersiContractorslEleclriciansfPlumbers.
TO BE FILED Whin THE PERMITTING Alrl"11OkITV.
Applicant Information Please Print Legibly
Name illosincss/orrganuanom'Individuall: �c's-T ovv,> ,v/1
Ads:__V. . ___11,7jar. _ L
City/State/Zip: VCC,(l.r ( 0(01,l Phone if: ' W — S—00")�
Art you an orilaytr?Creek re yiMerprfote ham:
Type of project(respired):
I.❑I am a cophiye with_____ __employees(full Angkorpml-firm)_•
7, p New construction
2n I am a Burk proprietor or partnership and have iar eriphryirs working tun me in $. l'Remwdelitg
any capacity_INo worker tramp.' w„p.imwamr rcyurnsl-1 '
30 I am a h znicown►a doing all you'll inyxlG lNu workers'comp.insurance nywnd_l'
4. ❑Demolition
10 Q Building addition
4.01 am a lu,nwrici and will be hiring Neral ism ill conduct all work on my property. I w ill
e �
nv cnure that all e9lraraeton tither Iave workers'c mpiait sior insuranceor arc sole 1 1 L rleelrica)repairs or additions
ton with no employees.. 12.0 Plumbing repairs or additions
5 I am a I,w-rieral contractor and I luv c hind the sub-contractors hstcd on the atached died.optic
13.1:1Roof repairs
These yob-.ontrxlun have employees and hale waakeri comp.insurance.;
14.0 Other till 6.0 w.an.c...reaimnd n a its officers hat lcex,rciscil thou m c right of cxcptrun per MU_ _
152.11(4),and we base no cnplusec's.[No workers'cuunp.insurance.required]
•Ana applicant tar chocks.box=1 must also till out du:-willow below showing their workers'compensation polity ialarrnui i..
t Iduincuwters who submit this atfativit indicating they an thing all work and then hire outside cuuractums newt submit a IIM affidavit imheatiug mark
't'untraetun that check this box must attached an additional sheet showing the name of the sut►coim.ietors and star whether or nut those entities have
employers. It the sub-contractors have crr{rlotecs.they must provide their istirkers'warp.policy number.
1 am an employer that is providing workers'compensation insurance for tar employees. Below is the policy and job site
information.
insurance Company Name: 1�vy Ght\r.,r./� (L‘111-A-) )
—
Policy n or Self-ins.Lie.#: Expiration Date:
+
Job Site Address: 17'` lAir--.5- ",c 1 (L L City Stale'Zip:__ t4._ +r —C .Clo Z
Attach a copy of the workers'compensation policy declared =page(thawing the policy number sad expiration date).
Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a tine up to S 1,500.00
aniVor one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to S250.00 a
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DiA for insurance
coverage verification.
I do hereby certify under the pains aanndpenalties ofperjurr that the information provided above is true andt correct.
Signature: `/'L!� Date Z--
\ 7ic1—1;<7/
Phone _ Ul\ j — 610�}
Official use only_ Do not write in this area,to be completedcityor town o aL
J= p by J�
('its or Town: Permitil icense#
issuing Authority(circle one):
1. Board of Health 2.Building Department 3.City/Iona Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
City of Northampton
opSM^MPra�, �S +'fI
~ Massachusetts.41
(- -it, DEPARTMENT OF BUILDING INSPECTIONSfe- 4 f
5
• f: 212 Main Street • Municipal Building J` s
Northampton, MA 01060
CONSTRUCTION DEBRIS AFFIDAVIT
(FOR ALL DEMOLITION AND RENOVATION PROJECTS)
In accordance of the provisions of MGL c 40, S54, a condition of Building Permit
Number is that all debris resulting from this work shall be disposed of in a
properly licensed waste disposal facility, as defined by MGL c 111, S 150A.
The debris will be disposed of in:
Location of Facility: V rik.
The debris will be transported by:
Name of Hauler: /^ w\,..)
G2�
Signature of Applicant: Date: